MEDICARE: MICHAEL DESMADRYL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11768	SC
2	225100000X	Physical Therapist	0019213	CO

General Provider Information

NPI Number	:	1720787773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DESMADRYL

Provider Business Mailing Address
First Line	:	4714 MILESTONE LN
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-7907
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4714 MILESTONE LN
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-7907
Country	:	US
Telephone Number	:	303-660-5349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2023
Last Update Date	:	07/12/2023

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Directions to “ MICHAEL DESMADRYL ” Practice Location

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